A school nurse evaluates a child who is chronically soiling underwear and shows no evidence of physical illness.
What is the priority nursing action?
Refer the child to a gastrointestinal specialist.
Reprimand the child gently to encourage control.
Report suspected encopresis and begin psychosocial evaluation.
Instruct the child to eat more fiber.
The Correct Answer is C
Choice A rationale
Referring the child to a gastrointestinal specialist might be considered later, but it is not the priority action. Since the child shows no evidence of physical illness, the most likely cause of chronic soiling is functional or psychological. Addressing the potential underlying psychosocial factors takes precedence over pursuing further physical diagnostics immediately.
Choice B rationale
Reprimanding the child gently is an inappropriate and potentially harmful action. Encopresis is often involuntary and can be a source of significant shame and distress for the child. Reprimanding can exacerbate these feelings, leading to further withdrawal and potentially hindering therapeutic progress rather than encouraging control or behavioral change.
Choice C rationale
Reporting suspected encopresis and beginning a psychosocial evaluation is the priority nursing action. Encopresis, in the absence of physical illness, strongly suggests a psychological or behavioral component. A psychosocial evaluation is critical to identify underlying stressors, emotional issues, or developmental factors contributing to the soiling behavior, facilitating appropriate intervention.
Choice D rationale
Instructing the child to eat more fiber is an intervention for constipation, which can be a contributing factor to encopresis. However, it's not the priority action when there's no evidence of physical illness and chronic soiling is present. Without addressing potential psychological factors, dietary changes alone are unlikely to resolve the complex issue of non-organic encopresis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Focusing only on the area around the nipples is insufficient for a comprehensive self-breast exam. Breast tissue extends broadly from the collarbone to the bottom of the rib cage and from the armpit to the breastbone. Limiting the exam to one area could lead to missed abnormalities in other regions.
Choice B rationale
Using the pads of the fingers with varying pressure allows for thorough palpation of all breast tissue. Light pressure assesses superficial tissue, medium pressure evaluates deeper tissue, and firm pressure reaches the tissue closest to the chest wall, ensuring complete coverage and detection of abnormalities.
Choice C rationale
While lying down is one recommended position, conducting the exam only in this position is not sufficient. Performing the exam both lying down and standing (e.g., in the shower) allows for different tissue distributions and helps in detecting abnormalities that might be more palpable in one position over another.
Choice D rationale
Performing the exam every day is too frequent and unnecessary. Breast tissue changes throughout the menstrual cycle, and daily exams might lead to confusion regarding normal physiological variations. Monthly self-breast exams are recommended for consistency and to establish a baseline for individual breast tissue.
Correct Answer is A
Explanation
Choice A rationale
Variable decelerations are characterized by an abrupt decrease in the fetal heart rate, often V, W, or U-shaped, and are primarily caused by umbilical cord compression. This compression reduces blood flow and oxygen transfer to the fetus, leading to a transient hypoxic event and subsequent FHR deceleration.
Choice B rationale
Maternal fever typically causes fetal tachycardia, an elevated baseline fetal heart rate (above 160 beats per minute), due to increased fetal metabolic demands and a direct effect of elevated maternal temperature on fetal physiology. It does not directly cause variable decelerations.
Choice C rationale
Fetal head compression typically causes early decelerations, which are symmetrical, gradual decreases in FHR that mirror uterine contractions. This occurs due to increased intracranial pressure stimulating the vagus nerve, leading to a transient slowing of the heart rate.
Choice D rationale
Polyhydramnios, an excessive amount of amniotic fluid, is generally associated with conditions like maternal diabetes or fetal anomalies. While it can alter uterine distension, it is not a direct or primary cause of variable decelerations, which are specifically linked to cord compression.
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